HESI LPN
HESI Fundamentals 2023 Test Bank
1. During a change-of-shift report at a long-term care facility, a nurse discusses an older adult client with shingles with an oncoming nurse. What information should the nurse include in the report?
- A. The location of the client's breakfast.
- B. The schedule for administering routine vital signs.
- C. The specific transmission-based precautions in place.
- D. The type of transmission-based precautions in place.
Correct answer: D
Rationale: The correct answer is to include the type of transmission-based precautions in the report. This information is crucial for infection control when caring for a client with shingles, as it helps prevent the spread of the virus to other clients and healthcare workers. Choices A, B, and C are not directly related to managing a client with shingles. Option A about the location of breakfast is irrelevant to the client's condition. Option B about vital sign measurements, though important, is not the priority when discussing a client with shingles. Option C mentions 'specific times the client had visitors,' which is not as crucial as knowing the specific precautions in place to prevent transmission of the virus.
2. A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse plan to implement when working with the client?
- A. Airborne
- B. Droplet
- C. Protective
- D. Contact
Correct answer: A
Rationale: Tuberculosis is an infectious disease that requires airborne precautions to prevent the transmission of infectious droplets. Airborne precautions involve wearing a mask, such as an N95 respirator, to protect against inhaling infectious particles. Droplet precautions are for diseases spread through respiratory droplets larger than those in airborne transmission, such as influenza. Protective precautions are not specific to respiratory infections and are more general measures to protect patients from harm. Contact precautions are used for diseases spread by direct or indirect contact, such as MRSA or C. diff infections, not for tuberculosis.
3. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic
- B. Obtain current client data to compare with expected outcomes
- C. Modify the nursing interventions to achieve the client's goals
- D. Review related professional standards of care
Correct answer: B
Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.
4. The patient has been diagnosed with diabetes. When admitted, the patient is unkempt and is in need of a bath and foot care. When questioned about hygiene habits, the nurse learns the patient takes a bath once a week and a sponge bath every other day. To provide ultimate care for this patient, which principle should the nurse keep in mind?
- A. Patients who appear unkempt may require guidance on hygiene practices.
- B. Personal preferences can be influenced by health conditions.
- C. The patient's illness may require teaching of new hygiene practices.
- D. Cultural perspectives on cleanliness can vary based on health status.
Correct answer: C
Rationale: In this scenario, the patient's diagnosis of diabetes may necessitate adjustments to their hygiene practices. The nurse should recognize that certain illnesses, like diabetes, can impact hygiene needs. Choice A is incorrect because appearing unkempt does not necessarily indicate a lack of importance on hygiene practices; it may be due to various factors. Choice B is incorrect as health conditions can influence personal preferences and habits. Choice D is incorrect as cultural views on cleanliness are not the primary focus when addressing hygiene practices related to a specific illness.
5. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family?
- A. Wear cotton clothing to avoid static electricity.
- B. Avoid using any electrical appliances.
- C. Keep the oxygen tank away from heat sources.
- D. Use only a specific type of nasal cannula.
Correct answer: A
Rationale: The correct answer is A: Wear cotton clothing to avoid static electricity. When using oxygen therapy, static electricity can pose a hazard as it increases the risk of fire. Cotton clothing helps reduce static electricity buildup. Choice B, avoiding electrical appliances, is overly restrictive and not entirely necessary. Choice C, keeping the oxygen tank away from heat sources, is important to prevent fire hazards but is not directly related to the nasal cannula. Choice D, using only a specific type of nasal cannula, is not a universal guideline and limits flexibility in care.
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